Isn’t it about time we end “Lazy Eye”?


girl-eye-exam_resizedAmblyopia is the most common form of unilateral vision loss affecting over 10 million individuals in the US alone. It is a disease of the visual system that impacts the lives of 2-4% of the world’s population yet occurs in the absence or removal of ocular pathology.  Amblyopia  is a serious visual problem that has been recognized for centuries as the inability to see in one eye compared to the other, even with corrective lenses.

However , there is an overwhelming amount of research evidence that shows amblyopia  impacts a person in more than visual acuity (eye sight) alone. The amblyopic individual has poor depth perception,  dysfunction in micro-eye movements affecting reading fluency, visual perception and processing ability causing poor judgments, deficiencies in eye hand and general coordination leading to errors in visually directed motor behaviors.

Modern neuroscience has provided us with the complete understanding for the cause of Amblyopia too. We know that Amblyopia is a preventable developmental disorder of binocular vision. That means  if there is a disruption in a child’s ability to use their two eyes either due to eye teaming failure (strabismus), unequal refractive error (anisometropia) or congenital cataracts during the sensitive developmental period of a child’s life, between age 6 weeks and 6 years, then amblyopia will occur.

But, there is something else very wrong with this picture. Why? Because, if amblyopia is such a serious disease of the visual system affecting millions  of children and adults,  why has it earned the distinct trademark in medicine known as “Lazy Eye”!  Why would such a serious disease be associated with the pejorative, “Lazy”?why

Indeed, it is the kind of question one might have expected from the great comedian George Carlin. If a child has a lazy eye, it must be because they brought it upon themselves, right? Carlin may have said, “Come on,  how hard can it be to work your two eyes together. Oh, those kids with lazy eye, they simply did not try hard enough! After all, look at all the “normal” kids who can make their eyes work together, just like play! That kid who can’t do something as simple as make his own eyes play together must be really lazy!”

Take it a step further. You learn from a school eye test that your child is having trouble seeing 104_AJB453_patch_188x156with one eye. So, you go to the eye doctor only to learn that your child has a condition called lazy eye and then what are you told? They have a “good eye” and a “bad-lazy eye”. To take care of the problem,  the “good eye” must be penalized by wearing a cover (eye patch) to force the “bad-lazy eye” to work harder.  So as a good parent you go along with the treatment and place  the patch on the normally seeing eye only to watch your child act out and refuse to wear the patch. Obviously, another  “lazy ” behavior to avoid the work of treatment!

Well what can you do? You have a child with one eye that is a “couch potato” and  they don’t  want to even wear a simple eye patch to fix it.  They behave like they would rather live with the problem and just be “lazy” about it!

lazydog

Let’s get serious! There simply is no other disease in modern healthcare that affects one side of the body or one organ and has earned the term “lazy”. If you have a child with only partial hearing in one ear, it is not referred to as “lazy ear”. If you have a child with only one working kidney you do not refer to the other as a “lazy kidney”.  So why “lazy eye” for amblyopia?amblyopia

There are many plausible explanations dating back centuries in medicine. But a bigger question is why, in the year 2015 have modern methods in eye care not been able to let go of an outdated mindset of amblyopia that dates back to the 1700’s?

The modern truth is that amblyopia is a serious vision disorder that has nothing to do with a person being lazy or an eye being lazy. Amblyopia is due to a binocular vision problem that affects the entire visual brain not one eye.  The common form of treatment known as occlusion therapy (patching)  and/or penalization,  while it has been the gold standard of care for decades,  has a well documented track record of serious negative side effects and limited outcomes.

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Fortunately,  now there is overwhelming neuroscience that shows that there is another approach to effectively treating amblyopia. Instead of occlusion therapy that has a slow response time, is harsh on the patient and the family trying to enforce its on their child and has limited results, there is a new better way that is enjoyable to the patient, gets faster and better results and improves more than just visual acuity alone.  The new emerging treatment paradigms involves binocular vision therapy woven into a computer gaming modality. When done under the supervision of the doctor and vision therapist, the patient responds faster, better and without resistance to treatment. And what’s more, research has shown, with binocular vision treatment in the form of perceptual learning, there is plasticity even in the adult brain. That’s right, with modern treatment amblyopia can even be successfully treated in adults.

However while we have a new and improved treatment for amblyopia, there still exists a bigger issue. Before we can embrace a new and advanced treatment for a serious vision disorder, there is a critically important first step that must precede it and that is the dialog. We must begin with  a new conversation.  This post is a call for support and recognition by all eye care professionals to dismiss the outdated, confusing and negative term “Lazy Eye”.  It should be removed from our professional and public vernacular. The condition is Amblyopia. But, as long as we refer to this vision condition with  a pejorative “lazy”, implying derogatory judgment, the longer it will take the doctors and the public to think if this condition as a serious visual problem that deserves a more serious approach in treatment than an eye patch, even when the research shows otherwise.

If you agree, how can you help with this effort to bring about a change in the way those with amblyopia (children and adults) are cared for by health care professionals?  It begins by how we speak about amblyopia, not as “Lazy Eye” but as Amblyopia.  Your help begins simply by sharing this message and allowing it to have social significance.  By all means, if you have been affected by amblyopia (either as a parent of a child, or as an adult with amblyopia), your personal experience and comments are also welcomed.

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Together, doctors and a concerned public, we can make a difference in the lives of those have been touched by amblyopia so that this serious vision problem no longer causes people to endure the frustration and emotional association of an outdated mode of care.

Dan L. Fortenbacher, O.D., FCOVD

 

16 thoughts on “Isn’t it about time we end “Lazy Eye”?

  1. Amen! We need to wipe out “squint” in the medical vernacular as well. I also discourage parents from using the term ‘bad’ eye. I tell them their child has two healthy eyes, one stronger and one weaker. We need to get the eyes equalized as much as possible so they can ‘play on the same team’ allowing the brain to knit the information from each eye together for a stronger more powerful visual system. Very nice article! Thank you very much.

  2. Well-stated, Dr Fortenbacher! There is a new review that just came out stressing the importance of this message: http://www.ncbi.nlm.nih.gov/pubmed/25637854
    From it’s abstract:
    Amblyopia is a neuro-developmental disorder of the visual cortex that arises from abnormal visual experience early in life. Amblyopia is clinically important because it is a major cause of vision loss in infants and young children … Individuals with strabismic amblyopia have a very low probability of improvement with monocular training; however they fare better with dichoptic training than with monocular training, and even better with direct stereo training.

    • Thank you Dr. Press! This brand new paper is one more “hot off the press” reminder that the evidence is clear, patching is not the best approach for the treatment of amblyopia and that binocular (dichoptic) therapy is. Now it’s time for doctors to embrace this and patients to have access to this treatment…if we can just get past the mind-set that amblyopia is only a “lazy eye”.

  3. I agree! And I like Dr. Vandervort’s wording and will start using that to explain it to parents and adult patients (if you don’t mind, Dr. V!). Thanks for the write up Dr. Fortenbacher. Gets you thinkin’…

  4. This article is trying to make something out of a non-issue. It’s just social justice warrior bullshit. I have never in my life, ever, had anyone attempt to associate the term “lazy eye” with some sort of a personal character fault.

    • Hi Patrick, I appreciate your honesty and responding to this post. Amblyopia is a unique condition in medicine whose name was adopted over 300 years ago when the ophthalmologists of the day coined the condition because of the apparent inability to coordinate the two eyes (one form of amblyopia due to strabismus). This inability to cooperate/coordinate led to a label of a “lazy eye” that has stuck around for centuries. Certainly, no doctor would suggest that they truly believe the patient to be lazy just because they have amblyopia. And this is not actually a suggestion that there is a character fault but rather what we are questioning is why does a very serious health issue have “lazy” associated with it in this day and age? And, more importantly does this attachment to an old way of thinking about this serious visual problem promulgate an old model of treatment, occlusion therapy as the mainstay in treatment, when occlusion therapy has proven to have limited results and many negative side effects on the patient’s quality of life? The question comes down to how long will it take for modern patient care to advance when the professional and public awareness hold onto an old way of thinking about this disease? First it begins with the way we communicate about the disease. Amblyopia is not simply a lazy eye it is a dysfunction of the person’s visual brain and that has a huge effect on their ability to function and succeed in life! The best, evidence based treatment is binocular vision therapy. But before this can be adopted, most doctors will need to change the way they manage their amblyopic patients. So, in the end it is not to imply that the individual with Amblyopia is lazy. Maybe the better question is, if those who are entrusted in the care of amblyopic patients and are still prescribing only occlusion therapy, are they the ones who are truly lazy?

  5. One more thought, Dr. Fortenbacher. There may be a qualifier to the discussion when amblyopia is deep. I’m not yet convinced, in looking at individual data rather than overall population data in these studies, that quality time occlusion is never indicated. If acuity is reduced to a low enough level on a monocular basis, there still may be select cases in which this provides a jump start preparing the brain to respond better to binocular integration or summation therapy. Parenthetically I’ve also seen cases where a very young child with IXT can’t undergo active therapy, and P-OMDs have Rxed part-time alternate patching which helped offset adaptation into amblyopia or constant unilateral strabismus. I had this discussion over the weekend with a College of Optometry faculty member who asked: “So are we ready to teach students that occlusion should never be undertaken in amblyopia?”

    • Thank you Dr. Press for bringing this important question to the discussion. Since this post is about the new evidence based advancements in treatment for amblyopia that emphasizes the benefits to the patient of a binocular approach vs a monocular approach certainly would beg the question, “Now that we know this, is there ever a place for monocular treatment in amblyopia?“
      And the answer to this question is, “yes, of course there is a place for monocular treatment!.” As in any advancement in medicine, just because there are new discoveries in treatment does not dismiss the rational for using the standard method for specific conditions. Just like the carpenter who only has a hammer in the tool box, everything looks like a nail. But when there are more tools in the tool box, then the work can be performed with greater accuracy and ease but does not rule out the need for the hammer. Amblyopia can be a very complex visual condition and therefore it is the doctor’s responsibility to know and understand the different forms of treatment and to prescribe what is best for the patient or refer to the developmental and rehabilitation specialist who will be able to do so.

  6. Hi, my question probably has nothing to do with this topic but I have found this page while watching a video on you tube and it seems helpful. I want to know if these exercises ,or any others, can help with Amblyopia if you are an adult ( I am 25 ). I had a problem with my doctors when I was child, they told me that my eye will be better as I grow older and that, of course, never happened. So my question is should I start with training my eye or it is to late for me.

    • Age is not considered the barrier that it once was in the treatment of amblyopia. However, effective treatment in adults requires an advanced amblyopia treatment model provided by a doctor who is trained and has the delivery of care using these advanced principles and techniques. I would recommend that you contact the College of Optometrists in Vision Development (www.covd.org) to find a Doctor nearest you to have a diagnostic visual evaluation and determine if you are a candidate for care.

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